…Keedy prefers the work to be viewed in the larger context of normalcy and otherness, and for the narratives of each image to stand on their own. He appears in some of the images not as himself, but as a character in a scene. The photos are supposed to be thought-provoking, not conclusive. It’s specifically the conclusive nature of diagnosing certain behaviors as abnormal that bothers him.

And below, my favorite image of the bunch because I can relate to it oh so clearly!

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According to this article in The Guardian, tomorrow the British Psychological Society’s Division of Clinical Psychology (DCP) will be releasing a statement calling for a “paradigm shift” in how mental health is understood. They are expressing concerns about the diagnostic assumptions being made by the DSM.

What’s fascinating is that the DCP’s problem with the DSM-5 is the opposite of the issue that the NIMH cited (and I wrote about last week). According to Dr. Lucy Johnstone, who helped draft the DCP statement, a chief concern was the focus on biological causality:

On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.

I think most medical anthropologists would agree, without denying the interaction of biology: chemical interactions with the environment, diet and nutrition, genetics and epigenetics, etc.

That groups are taking such diametrically opposed views in criticizing the same publication makes me wonder if the DSM-5 is being used as a scapegoat for long-held resentments and a catalyst for change. I don’t see the DSM as either particularly biological or sociocultural, but neither is it a moderate middle ground between two extreme views. It seems that each side is interpreting the DSM to create a foil for its goals.

In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

I had a moment of hope, that perhaps they would be looking beyond reported symptoms to cultural and structural as well as biological factors. Instead, NIMH is launching the Research Domain Criteria (RDoc) project to develop a classification system of its own. NIMH support in the future will be for research that cuts across DSM categories and fits the assumptions of RDoC (the emphasis is mine):

A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,

Each level of analysis needs to be understood across a dimension of function,

Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment

I’m not a doctor and I do believe that many illnesses that we see as “mental disorders” have a basis in chemical imbalances or biological disease. However, this sort of institutional bioreductionism worries me. It seems like a quest for magic bullet solutions rather than an understanding of the complex factors inside and outside the patient that contribute to what he or she is experiencing.

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Why are there so many homeless people in the US, so often suffering from mental illness? Because we closed the asylums, of course! That Q&A has become canon. But what would happen if we opened large psychiatric institutions again?

NPR has a piece on such a proposal: Colorado Weighs Reopening Psychiatric Hospitals for Homeless (including a short audio segment from All Things Considered). Though much of the impetus seemed to come from creating jobs and reusing an existing campus — Fort Lyon, which was once a veterans’ psychiatric hospital and then a prison — the plan would bus up to 300 of Colorado’s homeless people to the Fort, which would serve as a rehabilitation and transitional housing facility. At the end of the week, the bill to make this happen was shot down, but it will be added as an amendment to another bill.

Improving the plight of mentally ill homeless people should just be a matter of balancing cost/benefit of allowing things to continue as they are or bringing back the institutions, right? The solution is not a simple binary (and neither was the problem, I’d argue, though that has become the prevalent discourse). Even if we imagine a Utopian care and rehabilitation facility and not a dumping ground like Vita, is the best option to remove homeless people from the community, sweep them out of sight, and hope that budget priorities don’t empty them onto the streets en masse again?

Sam Tsemberis of Pathways to Housing is quoted in the NPR piece. “Having someone in transitional housing teaches people how to manage living in transitional housing.” I’ve heard a bit about the Pathways to Housing model in the past: it provides housing first — immediately taking homelessness out of the situation — and then adds needed counseling and treatment. (The website is very broken in Chrome; I didn’t check other browsers.) PBS NOW did a half-hour piece about the success of this approach, despite the obvious concerns it raises. [Watch video.]

The head of Colorado’s Coalition for the Homeless, John Parvensky, sees a need for both approaches to reach the range of people who find themselves long-term homeless.

“It’s not really a question of either-or: Should the state support community-based options or should they support Fort Lyon?” says Parvensky. “They really should be doing both, but historically they’ve been doing neither.”

Reading a number of Colorado news articles, it quickly became clear that what’s being debated is not the question of what’s best for homeless people. It’s about budget and jobs and veterans (an earlier proposal had Fort Lyon as transitional housing explicitly for homeless veterans). It’s about the corollary to the American Dream that says that everyone should pull himself up by his bootstraps and take personal responsibility for improving his life.

I’m not convinced that large inpatient institutions are the solution — my personal opinion is that they cause new problems without solving anything but how to hide inconvenient people — but it’s hard to argue that ignoring the problem is better for anyone involved. On my future reading pile: a list of psychology/psychiatry and social work studies on the Housing First approach (anyone have a good anthropological study to recommend on this?) The claimed cost savings of it soothe my fiscal conservative side, while a humanistic method that treats those on the streets as people first — not as junkies or crazies — appeals to my inner anthropologist. The phenomenological experience of being treated worthy of shelter must be so different than that of trying to get clean, find work, or stay on a psychiatric regimen while homeless in order to be considered for a housing program.

I agree with several of Greenberg’s points, perhaps the ones in which he’s most in sync with Allen Frances, but on others his approach is so antithetical to medical anthropology that I was arguing aloud as I read them. Consider his lack of distinction between illness, disease, and disorder and sentences like, “If they don’t have real diseases, they don’t belong in real medicine.” If he’s so opposed to the APA being the judge of psychiatric diagnostic criteria, I wonder whom he would appoint to be the arbiter distinguishing real from non-real diseases or even real from non-real medicine.

As I read the piece, I wondered if perhaps Greenberg was just not a good interviewee. Though other things he’s written have a cynical edge, the tone seemed off and there were inconsistencies. According to Greenberg’s website, he didn’t know that the format of the Atlantic piece was going to be Q&A with verbatim quotes, and he admits that he “said some pretty intemperate things… but only a couple are embarrassing.” Ah, that makes more sense. I’ll have to take a look at the book to get a better understanding of his arguments.

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Last night’s Colbert Report did a “The Word” segment about “medical leave”. No, not when you take time off from work for illness, but what people are calling medical repatriation. I’d only known that phrase as part of the travel insurance I buy when heading out of the country, to get me home in case I fall ill or am injured. Colbert’s segment is talking about something else, less euphemistically known as patient dumping. [Watch the video.]

The first example in the video is that of two undocumented workers in Iowa who were comatose after an automobile accident. They had insurance (which is rather remarkable and kudos to the unnamed agricultural firm that employed them), but it wasn’t clear to the hospital if long-term care would be covered. So, after less than two weeks, the hospital flew the unconscious men to Mexico and put them into a hospital in Veracruz. There’s a more complete summary from the Des Moines Register.

Fiscal responsibility is certainly important for hospitals, but patient care is supposed to be their raison d’etre. Medical repatriation is just one example of where those two purposes conflict. Writing in The American Journal of Bioethics last year*, Mark Kuczewski proposed that medical repatriation could be ethical (legality is a separate issue) if particular conditions are met:

(1) Transfer must be able to be seen by a reasonable person as being in the patient’s best interests aside from the issue of reimbursement. (2) The hospital must exercise due diligence regarding the medical support available at the patient’s destination. (3) The patient or appropriate surrogate must give fully informed consent to being returned to another country. (Kuczewski 2012:1)

There are some excellent peer commentary essays that critique his approach as well as a response from Kuczewski. Even if we accept his initial three requirements, it seems that the Iowa case falls far short. And, that was just one case. A recent report states that there have been more than 800 cases of attempted or successful medical repatriation from the US in the past six years.

The second example in Colbert’s piece is about a Las Vegas hospital accused of putting psychiatric patients onto Greyhound buses and sending them to other states without a support system in place at the destination. This practice came to light through a March story and a follow-up investigative report in April by The Sacramento Bee. The Nevada Department of Health and Human Services investigated and found that of 1,500 patients discharged from Rawson-Neal Psychiatric Hospital since 2008, ten had been bused off into the abyss without any support.

During the five-year period reviewed, Rawson-Neal maintained an aggressive practice of discharging patients to the Greyhound terminal in Las Vegas, sending them off, unaccompanied, with Ensure nutritional supplements and a limited supply of medications.

The second Sacramento Bee article notes that funding for mental health care in Nevada has been slashed in recent years, and that from 2009 to 2012, the number of discharged patients bused out of state from southern Nevada increased 66%. Or as Colbert puts it, “In America, we don’t turn a blind eye to the needs of our fellow man. So we need to send them someplace we can’t see them at all.”

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Gizmodo has an article this week about a room prototype built by inmates in Spoleto, Italy, who attended design workshops. It’s not intended to be a cell though it has the same dimensions; it is built with the lived experience of people who spend each day in a 96 square foot room. While the Freedom Room lacks the style of a tiny space by IKEA, the inmates designed it to have storage and useful surfaces. Does this remind anyone else of Sam’s “2010 Center” ideal prison in Dreaming of Psychiatric Citizenship: A Case Study of Supermax Confinement by Lorna Rhodes?

The former director of the prison had a thought-provoking reaction:

“The heavy, mortifying restrictions placed on furnishings and accessories… tend to sharpen the wits of the detainees, who will try to make every possible use of the objects they are allowed to keep…. I sincerely hope that Prison Administrations will consider and adopt this project to promote a ‘culture’ of prison life which, for the first time, may be determined to a certain extent by the inmates themselves.”

I find myself cringing at the idea of an inmate-determined culture, but that’s because my notions of incarceration are (thankfully) shaped more by HBO’s Oz than by personal experience. However, I think it makes a lot of sense to consult current or former inmates when designing prisons — not to make them cozy or vulnerable, but to see what basic human needs could be addressed without loss of security. As I write this, there are 52 comments on the Gizmodo piece. Some understand the Freedom Room as a design project, but there is also a lively debate about what living conditions for inmates should be. Some examples:

“I don’t get this. They are in prison. There should be 4 bare walls and a toilet. Why should they live in nicer housing than I do? This is insane.”

“…That being said, whether you had an accidental life altering decision or your just a person who is inclined to do bad things, you need to be punished with discomfort. This is how society is enforced and why most of 360 million people in America are not in prison.”

“Holy Hell, let’s just put everybody in a box for years and see if they come out the other side sane and happy for work and living in the real world. If you place these people in an environment that promotes penance, education and learning, this- to me- seems the better nature for how to deal with those whose lives have been so damaged by their circumstances.”

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I’m a devoted fangirl of intelligent autobiographical blogs that attempt to capture events and emotions as they happen to to share them with a wider audience who might not have access to that experience. This is why Watching the Lights Go Out is now in my regular reading list.

Dr. David Hilfiker was diagnosed with “mild cognitive impairment, almost certainly Alzheimer’s diseaes” last September and outed himself with the creation of this blog on January first. His account is insightful and inspirational, and he says he hopes to help banish some of the stigma of the disease. Take a look.

“What psychiatry presents as the liberation of the mad (from mental illness) is in fact agigantic moral imprisonment” asMichel Foucault claimed. Look here for more on psychiatric practice, DSM-5, and the dangers of the notion “if all you have is a hammer, everything looks like a nail.”